What You Need to Know About SALAD: A New Airway Management Technique

This month EMS World features a short article on a simple and effective adaptation of the SALAD (suction-assisted laryngoscopy airway decontamination) simulation system built upon the framework of a Simulaids Critical Airway Management Trainer. As the inventor of the original SALAD manikin concept, I reviewed this article with enthusiasm, as the SALAD training system was “released into the wild” as an open-source concept—that is, a project whose intellectual property was intended to be open and free, and to allow for improvement by individuals, organizations and commercial companies alike.

The authors of this article have simplified the construction of their SALAD manikin to include a manual pump that maintains the functionality and spirit of the original project. The SALAD manikin is now a commercial system available from Simulaids’ sister company, Nasco, a Wisconsin-based simulation and education company.

However, I still maintain that this is a project for which the adaptation of existing training equipment shows merit. Build your own SALAD system, or buy one from a U.S. company—but in any case, obtain this simulation system as an upgrade in airway training both for you and your organization.

I hope you find this article interesting and inspiring, as I have, and that it serves to bring both young and old prehospital providers back to the simulation table together to learn new skills, shore up old ones and build a spirit of teamwork that is needed in such a difficult profession as prehospital EMS work.

—James DuCanto, MD

The SALAD (suction-assisted laryngoscopy airway decontamination) technique has been taking the airway management world by storm. The technique, pioneered by Jim DuCanto, MD, staff anesthesiologist and director of the simulation center at Aurora St. Luke’s Medical Center in Milwaukee, allows for decontamination of the actively vomiting patient’s airway, control of continued emesis and intubation, all in a quick and easy manner. While the technique is simple enough to learn and teach, the actual creation of DuCanto’s manikin can be challenging. In this short article we will detail how our simulation lab at Delaware Tech created a low-tech, simple SALAD trainer.

First, a few notes on the SALAD technique. When performing this method of airway management, a rigid (Yankauer) suction catheter must be connected to a suction unit, with the hole that you would typically cover with your finger taped closed to allow for continuous suctioning (Figure 1). The patient’s mouth is suctioned and cleared via the suction catheter.

Next, the video laryngoscope (if you don’t have access to VL, a traditional laryngoscope will work) is placed in the mouth, with the blade carefully hugging the base of tongue during advancement. Lead the optics of the laryngoscope with the rigid suction catheter to prevent the light source and/or optics from being covered with airway contaminant.

As the blade is introduced into the patient’s mouth, the hypopharynx and larynx are suctioned with the catheter. The suction catheter is then switched to the left side of the mouth and inserted into the patient’s esophagus, where it will remain through the rest of the intubation attempt. (This allows the suction unit to collect the vomit that will otherwise continue to flood into the mouth.) The patient is then intubated, and after successful tube placement and confirmation, the suction catheter is removed to allow for securing of the ET tube via a commercial device. For a detailed video by Dr. DuCanto on how to perform the technique, visit EMSWorld.com/12285695.

DuCanto released this technique online, along with instructions on how to create the simulated vomit (a combination of xanthan gum, a few drops of food coloring and vinegar) and the simulator. He utilized some PVC tubing, a drill, some quick-connect hose adapters and a drill-powered fluid pump connected to an airway management manikin. While highly effective, the pump and drill will only last 1–2 sessions before needing replaced. Additionally, this method requires the use of electricity around a large amount of fluids.

Creating a Trainer

When adopting the SALAD technique into our paramedic lab, I investigated several ideas for creating a low-tech, portable method for creating a SALAD trainer. The manikin we use is the Critical Airway Management Trainer from Simulaids. We utilize this trainer heavily in our lab and find it holds up very well to the abuse of paramedic students.

To modify the unit for SALAD training, I simply disconnected the tubing from the manikin’s esophagus and inserted the discharge end of a handheld transfer pump (Figure 2). The intake tubing of the siphon pump is placed in the container holding the simulated vomit, and the instructor activates the pump to introduce vomit into the airway.

After the initial purchase of the manikin, this transfer pump, plus other standard disposables such as suction tubing and the video laryngoscope blades, are the only ongoing costs. We have found this setup to be highly effective, with the amount of vomit introduced directly controlled via the handheld pump. The students initially practice with just a small amount of vomit that is incrementally increased as they get more comfortable with the technique. Overall, this method of creating a SALAD trainer is great for instructors who want to utilize this technique in their lab but are looking for a low-tech, portable setup.

Chris Boyer, MPA, NRP, FP-C, is a lead instructor and simulation coordinator with the paramedic program at Delaware Technical Community College in Dover, DE. Chris is an experienced clinician, educator, conference presenter and an associate of the UCLA Prehospital Care Research Forum. Reach him at chris.boyer@dtcc.edu.